Bromley Healthcare Quality Account 2018-19

Quality Account 2018-19

Delivering high quality services in the community

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Quality Account 2018 - 19

Bromley Healthcare at a glance

Patients Workforce:
91.000 1,000

Patient contacts: Patient Services: 35
600,000 satisfaction: Locations: 25

Income: £50m 98%

Boroughs: 5 Commissioners: 100

Figure 1.0: Bromley Healthcare 2018-19 at a Glance

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Quality Account 2018 - 19 6
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Contents
10
Introduction 11
Part 1 11
14
Chairman’s statement - Raoul Pinnell 15
Chief Executive’s statement –Jacqueline Scott 16

Part 2 22
49
Bromley Healthcare quality priorities for 2018/19
Statements relating to the quality of the services we provide 54
Participation in clinical audits
Statements from the Care Quality Commission
Data Quality
Participation in CQUIN

Part 3

Our achievements for 2018 – 2019
Success stories

Part 4

Statements from stakeholders

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Quality Account 2018 - 19

Introduction

Welcome to Bromley Healthcare’s 9th Quality Account.

Bromley Healthcare was established in April 2011 as an employee owned social
enterprise; we have now grown to employ over 1,000 staff including nurses, therapists,
doctors and dentists. Bromley Healthcare’s community healthcare work ranges
from helping new parents to care for new born children to supporting the elderly to
continue living at home as long as they can, with services including therapy services,
health visiting, district nursing, school nursing and specialist nursing.

Bromley Healthcare aim to be the best community care provider that strives for the
provision and delivery of caring, safe and effective services to local people, either within
peoples home or close to their home and their community.

We know that staff who join us are passionate about caring for people and their
community, and that it is important to support them so that they can continue to be
compassionate; take pride in their clinical expertise and be innovative. We also
understand that healthcare delivery is constantly changing to improve people’s
experiences of care. The NHS Long Term Plan, published in January 2019, sets out an
ambition for services to be working closely together to provide joined up care for
patients. We are committed to working in partnership with patients and carers, other
health and social care colleagues and voluntary sector services to ensure that our local
community receives the best care for themselves and their families. We are an active
partner in the One Bromley network, where health and social care services are working
together with the voluntary sector to provide more joined up and improved care for
people who live in Bromley.

Why are we producing a Quality Account?

All NHS healthcare providers have been required to produce an annual Quality Account
since 2010. This requirement was set out in the NHS Next Stage Review in 2008.
Although a social enterprise, the activities Bromley Healthcare undertake are directly
commissioned NHS services, therefore we are also obliged and pleased to produce an
annual Quality Account.

Our Quality Account is a report about the quality of services provided and is available to
the public. Quality Accounts aim to enhance accountability to the public and engage the
leaders and clinicians of an organisation in their quality improvement agenda.

The Quality account looks forward to 2019/20 as well as looking back on 2018/19. We
are keen to share information with service users, patients and their carers about the
current quality of all our services and our plans to improve even further.

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Quality Account 2018 - 19

What are the required elements of a Quality Account?

The National Health Service (Quality Accounts) Regulations 2010 specify the
requirements for all Quality Accounts. We have used the requirements as a template
around which our account has been built. The Quality Account is laid out as follows:

Part one

Statements from the Chairman and Chief Executive about the Quality Account.

Part two

Priorities for improvement – this forward looking section identifies our five priority areas
for improving the quality of our services for 2019/20, why we have chosen these
priorities and how we are going to develop the capacity and capability to achieve them.
Mandatory statements - relating to the quality of our services, as set out in the Quality
Accounts Regulations 2010.

Part three

Review of our quality priorities and performance in 2018/19, and examples to illustrate
ongoing improvement in our services.

Part four

Statements from our Commissioners, Healthwatch and the Patient Reference Group.

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Quality Account 2018 - 19

Part One

Chairman’s statement – Raoul Pinnell

I hope that we will never ever be fully satisfied. Achieving
quality is an objective that is both a destination and a
journey, which does not end. We should continue to expect
more of ourselves as we acknowledge that those whom we
serve expect ever higher standards.

Joining up care has become a mantra for the health and
social care sector. One of our responses has been to
develop and launch our Care Coordination Centre. This is
emerging as a critical enabler to improving our contacts
with patients and how we continue to manage their
appointments and respond to their needs.

There is much comment in the press about the need for suitably qualified staff in the
NHS. We acknowledge our responsibility to respond to this issue by ‘growing and
developing’ our staff. We have launched new programmes to train and develop staff and
introduced new roles. We have also gained new entrants to our sector by embracing and
employing new people with the support of the government’s Apprenticeship scheme.

We have reflected on the state of our premises to ensure that they are in line with the
needs of both our staff and patients. This has led us to relocate some of our clinics and
our rehabilitation unit. We are now planning a move to change some of our office
premises, which should help us to further improve our Care Coordination Centre.

All of the above requires behind the scenes skills to introduce new IT in the form of
equipment such as iPads for nurses. The latter offers improvements in the efficiency
with which we can capture patient information and offers the potential to do it with
greater accuracy. Much of this produces data and information which, when applied
skilfully,should also help to make further improvements in care.

The NHS Long Term Plan places a spotlight on the future role that ‘social prescribing’
will be able to play in supporting patients to manage conditions. Our work in supporting
the Bromley Healthcare Charity and a closer relationship with the Voluntary Sector in
Bromley should help us to make a further step on the road to both integrating and
improving care in our community.

Raoul Pinnell
Chairman

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Quality Account 2018 - 19

CEO’s Statement – Jacqui Scott

Our aspiration is to provide the best care possible to
enable patients and carers to live healthier, happier lives
and receive their care and support closer to home. I have
great pleasure in welcoming you to our 2018/19 Quality
Account which charts our progress over the last year and
the quality initiatives we will be working towards during
2019/20. Every opportunity is taken to encourage
feedback from patients and carers to help improve our
care; the National Friends and Family Test, is one such
modality, with 98% of patients responding as either likely
or extremely likely to recommend our services. (This was
top in London and in the joint second nationally.)

Our committed Patient Reference Group participated in a number of initiatives
including ‘mystery shopping’ of our care coordination centre as well as reviewing our
leaflets and website to drive improvements.

The good patient outcomes and high satisfaction levels achieved are due entirely to
the outstanding commitment from our team. The quality objective building a ‘culture for
growth’ places a continued focus on ‘growing, developing and improving the
experience of our team. The entire staff journey has been mapped with a number of
specific initiatives put in place to support every step of the journey. A focus on
attraction and recruitment has reduced the vacancy rate from 12.8% to 7% with more
permanent and internal bank staff in teams; starting to reduce the reliance on agency.
A Staff Forum has been set up to provide a direct communication channel between
team representatives and the senior management team.

Our patient centric Care Coordination Centre plays a significant supporting role in
ensuring continuity and consistency of patient care. The centre is the first point of
contact for our 35 services; looking after 12,000 patients and answering 26,000 calls a
month. Over the next year, the continued evolution of the centre will focus on best
practice pathways and quality assurance facilitated by the use of our ‘near live’ safety
dashboards to proactively promote safety and prevent incidents.

Some of the key highlights over the last year are:

 Introduction of the bespoke Nursing Band 5 Development Programme for newly
registered nurses. The intensive programme provides a focussed target on clinical
skills, immediately followed by clinical practice with tailored lists of patients. At the
end of the programme the nurses were fully competent in the essential
competencies for their roles.

 Hollybank, our short break service, received a ‘good’ rating in all three domains
following an unannounced Ofsted inspection in November 2018.

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Quality Account 2018 - 19

 Our Talk Together Bromley service improves access to psychological therapies with
satisfaction rates remaining at over 97% and the service exceeded the national
targets in access, waiting times and recovery rates.

 In the first full delivery year of our new ‘outcome based’ contracts our Key
Performance Indicator has been achieved for both the Adult and Children’s
contracts.

 Outcome measures developed for every service to demonstrate improved outcomes
for patients following their care; in the leg ulcer service 88% of simple venous leg
ulcers were healed within 12 weeks and 100% of complex venous leg ulcers were
healed within 18 weeks.

 Introduction of the ‘daily safety huddle’ using our ‘near live’ safety dashboard to
drive improvement resulting in a reduction of missed visits.

 The successful relocation of the rehabilitation beds to the Foxbury unit with positive
patient feedback received about the move and the new location. The National Audit
of Intermediate Care also found the service to demonstrate exceptional (positively
deviance) performance in outcomes, despite facing the same constraints as others.

 Our Bexley 0 to 19 service has continued to go from strength to strength over the
last year with the majority of Key Performance Indicators either being delivered
above the target of 90% or close to it with 97% satisfaction from families.

 The Charity Ball and Awards evening was a wonderful event attended by over 220
staff and volunteers to celebrate their many achievements.

Finally and most importantly, I wish to thank our amazing Bromley Healthcare team
who continually demonstrate their resilience, compassion and passion in the care and
support they provide.
.

Jacqui Scott
CEO

The information provided in this report is, to the best of our knowledge, accurate and a
reasonable reflection of our commitment to quality.

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Quality Account 2018 - 19
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Quality Account 2018 - 19

Part 2: Our quality priorities for 2019-20

In this part of the report we will focus on 2019-20. Our priorities for improvement reflect
the learning from preparation and feedback from our CQC inspections across 2017/18
and 2016/17 and are underpinned by defining quality against the 5 CQC core standards
for a healthcare organisation:

 Safe
 Caring
 Responsive
 Effective
 Well led

These objectives are also reflected in the organisations business plan for 2019/20. Our
quality objectives for 2019-20 are illustrated in figure 2.1:

Aspiration Initiatives How we will measure success

Patient care  Phase two development of  New CCC model in place working with partner
delivered at our Care Co-ordination organisations
best value Centre (CCC) Introduction
of E-community system  Reduction in waiting lists by 10%
(Effective  Reduction in DNAs/WNB by 1%
and  Introduction of Proactive  District nursing patients provided with
Responsive) Care Management
pathway timeframe for their visit in advance
 Improved outcomes for Patients for the Stock
 Introduction of telehealth
technology Hill Practice pilot

Patient at the  Utilise patient feedback to  Patient satisfaction greater than 90%
centre of their drive service improvements  Patient engagement greater than 3%
care  Zero ‘never events’ (preventable incidents)
 Introduction of preventative
(Safe and (near-live) patient safety for 2019/20
Caring) dashboard  Zero missed insulin visits

Culture for  Expansion of our Health  Expand the health and wellbeing initiatives
growth and well-being offer – successfully launched in17/18
mental health and well
(Caring and being and cancer support  Improvement in staff satisfaction survey results
Well Led) (by 5%)
 Delivery of staff survey
action plan  Reduce Vacancy rate (to 5%)
 Reduction in Community Nursing vacancies
 Delivery of bespoke
community nursing by 10%
programmes  Recruitment of school leaver apprentices
 Talent Management programme launched and
 Talent Management
programme in place evaluated
 Internal Promotion

Figure 2.1: Quality Objectives 2019-20

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Quality Account 2018 - 19

Statements relating to quality of NHS services provided

In this section of the report we will make several statements relating to the quality of
the services we provide. This allows direct comparison with similar organisations and
service users and commissioners can be assured that we are a quality focussed
organisation who are engaged in many activities linked to quality improvement.

Review of services

During 2018/19 Bromley Healthcare provided a range of community health services
across Bromley, Bexley, Lewisham, Greenwich and Croydon providing some 600,000
patient contacts.

During 2018/19 Bromley Healthcare provided 35 NHS services. Bromley Healthcare
has reviewed all the data available on the quality of care in all of these NHS services.
The income generated by the NHS services reviewed represents 100 per cent of the
total income generated from the provision of NHS services by Bromley Healthcare for
2018/19.

Participation in clinical audits

Local audits

Local audits are important in measuring and benchmarking a range of activities against
agreed markers of good professional practice, stimulating changes to improve practice
and re-measuring to determine any service improvements. Robust audit also
contributes to assuring both our commissioners and regulators of the quality of
services being provided. Clinical audit is just one quality improvement tool. An audit
programme should reflect priorities for services and organisations and should be
informed by various intelligence such as complaints and incident data and the patient
experience. Therefore, our audit programme can be added to at any point throughout
the year and not all audits will be completed within a financial year.

Examples of key learning from the audits include:

Bladder and Bowel service Catheter Audit Programme

Our Bladder and Bowel service routinely monitors and audits its patient cohort to
identify patients who have a urinary catheter for more than 28 days as part of our
current contract. To achieve this the service receive a weekly report from our Emis
clinical information system on long term catheter care which lists all those patients over
28 days.

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Quality Account 2018 - 19

Based on the findings of patient numbers the service decided to standardise referrals
from the District Nursing (DN) service to the Bladder and Bowel service for patients
with "troublesome" catheters that cause stress for patients, repeated DN visits and
unnecessary visits to A&E.

The DNs have been given Catheter troubleshooting information and this is actioned
before a referral is made. If the catheter continues to cause problems the DN can now
request a joint visit with a member of the Bladder and Bowel team.

This process has been developed involving the Bladder and Bowel service, Emis
Team, the Care Co-ordination Centre and District Nurse service Leads.

This approach was established in March 2018 and will assist in reducing the number of
referrals needed for specialist intervention through the support provided to DNs to
manage catheter issues at the earliest opportunity. A Catheter link group has also
been established and has been running since August 2018. The group meets bi
monthly, with 1or 2 DNs from each team in attendance to support information sharing,
education and support.

Management of Pressure Ulcers

There were 9 serious incidents reported in 2018/19 of these 5 related to pressure
ulcers. Following a review of these individual cases there is now a policy in place for
staff to follow. Additionally processes have been reviewed to guide staff on reporting. A
further audit on pressure ulcers was carried out in May 2019.

Contribution to national audits

Of the national clinical audits and national confidential enquiries published on the
Healthcare Quality Improvement Partnership’s website, Bromley Healthcare
participated in the National Audit of Intermediate Care (NAIC) during 2018/19.

The NAIC found Bromley Healthcare rehabilitation beds service to be positively
deviant. Positive Deviance focuses on those health care services who demonstrate
exceptional (or positively deviant) performance in a particular area, despite facing the
same constraints as others.

The Benchmarking process classed teams who had a larger mean percentage
increase in the standardised clinical outcome measure (the Modified Barthel Index) as
being high performing i.e. positively deviant.

There were 124 service providers who took part in the NAIC survey in 2018, providing
data for 226 bed based services.

The findings are detailed in Figure 2.2.overleaf.

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Quality Account 2018 - 19

Title of Findings % cases
audit required

National Crisis response services (Rapid Response Team)
Audit of
Intermediate  Bromley had the ninth largest number of referrals of 73 providers.
Care (NAIC)
2018  Service user’s time waiting for the service was within the
interquartile range

 Bromley healthcare’s service provides a shorter length of stay than
average suggesting the service operates differently to other
providers in the audit

 The team completed more assessments per head than any other
service highlighting the team’s efficiency

Home based rehabilitation services

 On average Bromley’s service users have a much shorter wait time
from referral to receiving care than those of other providers

 Service duration is below the mean, indicating that service users are
ready to be discharged sooner

 Dependency levels show that for Bromley Healthcare’s service
users have similar dependency level (13.7) to other providers to
the mean (13.9)

 On discharge the average dependency score for Bromley (7.2) is
better than the mean (9.8) meaning on average greater
improvements are being made in a shorter time

 The number of contacts per whole time equivalent clinician is in the N/A
upper quartile. This indicates that the members of the team are each
seeing a higher number of service users than other providers

 The number of staff in post is in line with the interquartile range and
above average

Bed based rehabilitation services (Foxbury Unit)

 Intermediate care aims to support older people to stay out of
hospital. The service has a higher than average proportion of users
discharged to their own home

 The service was at the top end of the interquartile range for
accepted referrals

 The service has a lower average length of stay than other providers.
This is despite the average Modified Barthel score for the service’s
patient being lower at 50.5 than the average of 54.5, indicating

patients had a lower than average level on independence and greater

needs

 Patients admitted to the service had a greater level of need on average
but had a greater improvement in their independence, with a mean
score on discharge of 80.0, better than the average mean of 73.5

 Patients rating of their experience with the service was within the
interquartile range

Figure 2.2: National Audit of Intermediate Care

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Quality Account 2018 - 19

Statements from the Care Quality Commission (CQC)
and the Office for Standards in Education, Children’s
Services and Skills (Ofsted)

Bromley Healthcare is required to register with the Care Quality Commission and its
current registration status is full and unconditional.

The Care Quality Commission has not taken enforcement action against Bromley
Healthcare during 2018/19. The organisation has a Nominated Individual and Registered
Manager who works with the CQC to ensure that services are compliant with the five
essential standards of care: Safe, Caring, Responsive, Effective and Well Led.

The CQC have been invited to attend some of our governance meetings including our
Board meeting as well as regularly meeting with the Chief Executive Officer and Operations
and Safer Care Director. During our most recent visit in 2016/17, the CQC published
reports on the following services we provide:

CQC Beckenham Beacon inspection result

In November 2016 (our last inspection date), the service achieved an overall rating of
Good:

Safe Good
Caring Good
Responsive Good
Effective Outstanding
Well Led Good

The inspectors stated that:

‘Staff continually sought to exceed the expectations of patients and their relatives
by providing individualised care that improved their social wellbeing as well as
meeting their physical needs.’

‘Staff provided a caring, kind, and compassionate service and we received
positive comments from patients.’

‘We saw positive local leadership within the service and staff reflected this in
their conversations with us. Staff were supported in their role and had
opportunities for training and development. There was a positive culture in the
service and members of staff said they could raise concerns with the leadership
team.’

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Quality Account 2018 - 19

Ofsted inspections at Hollybank Children’s Respite Service

Hollybank, our short break service for children and young people with complex needs
had a full Ofsted inspection in December 2018. The service received a good rating in the
3 assessed categories:

Overall experiences and progress of children and young people Good
How well children and young people are helped and protected Good
The effectiveness of leaders and managers Good

Comments from the Inspector noted that the children and young people benefit from
positive relationships with a stable staff team that knows them well. The Inspector went
on to note that staff display genuine warmth and care towards the children and young
people which helps children and young people feel safe, secure and able to enjoy their
stays in the home. Staff provide high levels of supervision and the provider works in
partnership with the professional network to respond to any safeguarding concerns
and leaves no stone unturned to ensure that any incidents that are rare are thoroughly
and independently investigated. Any learning is used to improve practice.

Hollybank routinely receives positive feedback from parents and service users. Some
examples of feedback received are detailed below:

“Thank you so much for everything you did with me over the years. You made my
stays at Hollybank fun and made me feel safe and the staff were like a family.”

“You guys do such an outstanding service, I cannot stress what a difference it
makes for us to know that our child is in safe hands.”

“Thumbs up to all the staff for making my children welcome and happy in their
first night away from home. Thank you very much.”

“I no longer worry - sometimes I even forget to call and check in - it’s like he is
with family. Staff are brilliant-involves family in care and communicate well with
me. It is a great service and was a lifeline when my son was at his worst-
appreciated this support so much.”

Data Quality

We accept responsibility for providing good quality information to support effective
patient care. We comply with NHS information governance processes and are
supported by our Medical Director who is currently our designated Caldicott Guardian
and the Commercial Director who is the Senior Information Risk Officer (SIRO).

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Quality Account 2018 - 19

The majority of our services continue to use electronic record keeping through EMIS
which provides a single information system and significantly reduces the number of
times a patient is required to give personal information because relevant data can be
shared electronically between the clinicians involved in their care. All of our clinical
systems are brought together in our Business Intelligence reporting suite. This suite
uses Alteryx to mine, standardise and blend the data from all sources, which enables
our informatics team to report seamlessly across all systems and for all services

Data Security and Protection Toolkit attainment levels

The year 2018/19 was the first year of use for the new toolkit as it replaced the older
version of the Information Governance Toolkit. The new Data and Security Protection
Toolkit (DSPT) is based on the National Data Guardian’s 10 Data Standards. This new
toolkit focuses heavily on ‘Information and Cyber Security’ and will start introducing new
requirements within the next few years.

Unlike the previous toolkit, which had 3 levels of achievement, the new toolkit simply has
mandatory or non-mandatory requirements, with organisations being required to meet
ALL the mandatory requirements in order to pass. Therefore, unlike previous years,
there is no scoring to compare against. Bromley Healthcare met all the mandatory
requirements except training, where we achieved a 90% compliance against the 95%
requirement.

The DSPT was reviewed by the Commercial Director (Senior Information Risk Owner)
and signed off by the Chief Executive prior to submission.

Clinical coding error rate

Clinical coding is a process which translates the medical language of patient’s records
into an internationally recognised code describing the diagnosis and treatment of a
patient. Bromley Healthcare is not currently subject to the Payments by Results clinical
code audit.

Participation in CQUIN

The Commissioning for Quality and Innovation (CQUIN) programme for 2018-19 was
developed and agreed by Bromley Healthcare and our commissioners, Bromley Clinical
Commissioning Group, based on data intelligence from varying sources and
stakeholders.

Bromley Healthcare’s new community contract came into effect in December 2017. As
such the first year of the contract was exempt from the delivery of CQUIN schemes. As
a result the local schemes for the last year were delivered in the period December 2018
– March 2019.

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Quality Account 2018 - 19

The indicator goals for the local programme were agreed with the Commissioners to
address areas identified for improvement. Progress against CQUIN’s is shared internally
with the Executive and Quality and Performance Committees. All CQUINs are reported
to local commissioners on a quarterly basis as part of CQUIN monitoring.

Further information on each CQUIN indicator can be found below.

CQUIN: Falls Prevention System Review

Background

London Borough of Bromley’s Public Health Department undertook a Bromley falls
prevention system review in 2018 and as a result, made recommendations on how the
system could become more integrated and falls prevention strengthened across the
various organisations involved. The CQUIN was to help to advance integrated working
and provide savings in the form of reduced hospital admissions and the impact on
social services.

CQUIN Proposal

There are significant benefits to promoting falls prevention in the community, in terms of
both quality and patient care.
Bromley Healthcare already provides a Falls and Fracture Prevention Service and by
enhancing joint working with other providers, developing a common approach to identify
and provide interventions in the community, it will thus avoid duplication, raise
awareness of what is already available in the borough and provide the foundations of
more joined up care for patients and promote the benefits of an Integrated Care System.

Results

The CQUIN was achieved with through stakeholder meetings and communications.
Services across all providers were mapped and a draft proposal document developed
to enhance integrated working. A training plan was created across key stakeholders to
carry out falls prevention training. National reporting was maintained and reviewed to
ensure Bromley Healthcare were reporting correctly. We also looked at how we could
identify regular fallers and themes across the patient group and from the acute setting
(Princess Royal University Hospital) to enhance prevention for high risk patients.

CQUIN: Introduction of a preventative (near live) patient safety
dashboard

The successful implementation of this CQUIN is detailed in Section 3 Our achievements
in 2018/19 on page 41.

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Quality Account 2018 - 19

CQUIN: Adult Equipment

Background

Currently the provision of community equipment is included within a local authority
contract with the provider, Medequip. This arrangement is part of a London Consortium
where a number of other London boroughs have contracts with this provider. Equipment
is ordered via an on-line portal called TCES, to which local organisation staff including
Bromley Healthcare clinicians have been given rights to access and order community
equipment for patients.

Over the last few years the equipment spend has risen significantly above expectations
and both London Borough of Bromley (LBB) & Bromley CCG have worked with
organisations who now have in place control measures:

a) On-line training for all prescribers

b) Separate Teams set up on TCES to help identify who is prescribing

c) Nominated authorisers responsible for checking their staff orders.

d) Increasing equipment collections where equipment is no longer required.
e) Organisations nominating representatives to attend ‘equipment’, ‘operational’ and

‘budget’ meetings.

However whilst the Bromley Clinical Commissioning Group and the London Borough of
Bromley are putting measures in place to review the equipment available to ensure this
meets the increasing acuity of patients in the community, they are also seeking
assurance from organisations that they have clear oversight on the prescribing practice
of their staff and have developed internal protocols to manage equipment provision.

CQUIN Proposal

Bromley Clinical Commissioning Group is aware that Bromley Healthcare has the highest
number of teams and prescribers who have access to the system currently. Over recent
years there have been reviews of equipment provision which has led to organisations in
the system (including Bromley Healthcare) taking responsibility for prescribing which has
led to a drop in provision from 71% to 48%. Bromley Healthcare remains the organisation
with the highest demand and consequently spend, mainly in our Community Nursing
teams.There is an increasing demand to maintain patients in the community, prevent
unnecessary hospital admissions and support hospital discharge. Increasingly complex
and elderly patients means an increase in patient need which has an impact on the
overall equipment provision requirement.

London Borough of Bromley carry out regular audits of equipment prescribing, however
this does not extend to ‘health’ teams. The CQUIN aimed to provide assurance around
the prescribing of equipment by Bromley Healthcare.

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Quality Account 2018 - 19

This CQUIN was formed of three parts:

Part 1) Management of Equipment: We reviewed the internal management of
equipment including developing an Equipment Protocol which included:
 prescriber/authorisers

- clarification around the role and responsibilities
- monitoring numbers within each team to ensure adequate cover
 budget accountability – senior responsibility for monitoring team spend
 clinical practice & equipment training
 definition of role of Equipment Leads or Champions from various professional groups

Part 2) System wide Review of Equipment Provision - As part of an overall
CCG/LBB review into equipment Bromley Healthcare:
 ensured appropriate specialist staff are available to assist with reviewing the current

equipment catalogue, providing advice on alternative equipment for example pressure
care & therapy equipment, as well as attendance at Equipment Operational Group to
ensure input into operational issues.
 nominated senior staff to attend Budget review meetings to provide accountability for
prescribing practice and spend against the overall budget.
 be party to discussions around future provision of equipment to support hospital
discharge and maintain patients in the community/avoiding hospital admission.

Part 3) Peripheral Stores - ensuring access to local stock supplies is essential to
ensure timely provision of smaller items of equipment & reduce spend on delivery (due
to the location of the Medequip depot in Woolwich). We were asked to:
 ensure an adequate number of peripheral stores to support community teams
 put in place a stock management – protocol and stock take

Results

All of the CQUIN actions were completed and the process did identify some key areas
for improvement. Senior operations and clinical staff were identified for the management
and champion roles as well as the list of prescribers and authorisers being brought fully
up to date. Prescribing practice and stock audit were the main issues identified and will
be part of a plan to implement in the coming year. These changes will likely make small
improvements to the contract spend but will also allow us to complete a more in depth
analysis of the way we prescribe in future and will help us to make efficiencies in the
years to come.

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CQUIN: Children’s Equipment

Background

There are significant challenges within the system for occupational therapists working
in health for Bromley Healthcare and for social care in the Local Authority (London
Borough of Bromley) in providing equipment to their patients. The separation between
health and social care caused by national commissioning boundaries can create
confusion. It was highlighted that there was a lack of clear local guidelines agreed by
Bromley CCG and London Borough of Bromley in addition to national guidance. The
funding routes and ordering processes are diverse and were identified as on occasions
creating delays. Stock control and visibility could be improved as well as better
communication and clarity between prescriber organisations.

Proposal

The CQUIN was a programme to map and work towards resolution of the equipment
challenges in the system. The project manager worked with health and local authority
service leads, managers and staff as well as commissioners to compile a catalogue of
challenges for both health and social care. The project manager worked in close
collaboration with the CCG and LBB and ensure open communication lines. Although,
the project identified the challenges for health and social care, the aim was to ultimately
benefit Bromley Healthcare pathways and processes to be clarified and the system to
work in a smoother way, reducing the burden of equipment challenges on health staff.
The outcomes of the CQUIN were intended to reduce the period of time for which
children and parents / carers are waiting for equipment, or are waiting for a decision on
specialist equipment. It was also intended to reduce clinical time spent on navigating
equipment ordering processes by clarifying the protocols for equipment, and therefore
increase clinical quality of services after the conclusion of the project.

Results

The CQUIN actions were completed with a new policy for equipment developed within
Bromley Healthcare. The policy sets out responsibilities, processes and escalation
across the relevant services and organisations to form a basis for all parties to work
from. Clear reference to national guidance including the Care Act 2014 and the NHS Act
2006 is provided, linked back to local processes. Prescribing practice reviews were
carried out and a full issues and solutions paper created which will form the basis for
future improvements to the service. These improvements will be implemented in the
year 2019/20.

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Quality Account 2018 - 19
21

Quality Account 2018 - 19

Part 3 our achievements for 2017-18

This section reflects on our performance against the quality priorities set in 2017-18.
These priorities were set in line with our commitments to defining quality against the
against the 5 CQC core standards:

 Safe
 Caring
 Responsive
 Effective
 Well Led

Effective and Responsive – Patient Care will be delivered at
best value

Our Aim Achievement

Optimisation of the Care Co-ordination Centre Complete

The Care Co-ordination Centre (CCC) was launched in January 2018, following a pilot in
2017. Services were migrated across during the rest of the year. Currently the CCC
provides the first point of contact to patients across 35 services. The drivers for change
were based around ‘doing things in the right way.’

As well as Patient / Carer communications, the CCC team’s focus is to manage waiting
lists, Did Not Attends/Unable to Attends and adherence to patient pathways through the
use of live dashboards to provide a consistent patient journey. The aim is to use this
process to innovate to ensure that Bromley Healthcare, as part of the wider health
economy is ‘doing the right things’ with proactive care coordination and development of
patient pathways that reflect best practice and positive outcomes.

The CCC ensures that our patients receive our services in the right place at the right
time.

An overview of the CCC activity during 2018/19 is detailed below:

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Quality Account 2018 - 19

Figure 3.1 Care Co-ordination Centre summary

Achievement of Key Performance Indicators

A key benefit of the creation of the CCC was the standardisation of all of the
administrative support provided to clinical services across Bromley Healthcare. This
enabled us to evaluate guidelines and procedures to implement the most effective
processes. This includes, but is not limited to, the management of waiting lists, booking
of appointments, management of DNAs and cancelled appointments as well as triage
outcomes and priorities given to patients. This links into the reporting element of the
CCC where we use dashboards and EMIS (our clinical Information system) reporting to
proactively manage wait lists. The impact of this on the KPIs has been significant,
helping us to increase the KPI %s around waiting times and communications.
As a result this has had a positive effect of our performance:
 90.70 % of KPIs were achieved in Adults’ Services and 84.60% in Children’s Services

at end of February 2019 (against 70% target)
 Adult’s Services overall achieved higher activity than planned in the first year of the

contract: December 2017 – November 2018 with +0.4% above baseline.
 Children’s Services overall achieved higher activity than planned in the first year of

the Community Services contract: December 2017 – November 2018 with +21.7%
above baseline.

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Quality Account 2018 - 19

Reducing Did Not Attends (DNA) and Unable to Attends (UTA)

In the recent National Community Benchmarking, our Adult services had a DNA rate
lower than the mean benchmarking rate for 12 out of 14 services, whilst the Children’s
services had a Was Not Brought (WNB) rate lower than the mean benchmarking rate for
all 6 services.
The impact of the CCC in reducing DNA and WNB for our adult and children services is
shown below in figures 3.2 and 3.3.

Figure 3.2 Benchmarking DNA Comparison

Figure 3.3 Benchmarking WNB comparison
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Quality Account 2018 - 19

Reduced Waiting Times

The focus of the CCC of ensuring appointments are filled has delivered significant
improvement in reducing waiting times.
The impact on our Podiatry Children’s Physiotherapy services are illustrated below in
figures 3.4 and 3.5

Figure 3.4 Podiatry average waiting time

Figure 3.5 Physiotherapy average waiting time
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Quality Account 2018 - 19

Our Aim Achievement

Focus on delivery of service standards through strategic review Complete
meetings and increased staff led quality improvement initiatives

Bromley Healthcare recognises that continuous review is fundamental to the
development, delivery and monitoring of our services. Systematic review of all clinical
and corporate services has therefore been a key focus in the last year with named
leadership roles to drive through resulting actions. The strategic review process has
been based on the principles of

 Staff motivation and engagement
 Transformational leadership and accountability
 Organisational collaboration

The initial reviews of our services were completed in between March 2018 and
December 2018. With follow up scheduled 3 - 6 months post the initial reviews to
monitor progress against actions identified. To ensure a consistent approach reviews
were structured to include the following areas:

 Achievement of operational performance
 Achievement of service standards
 Achievement of outcomes
 Patient satisfaction
 Delivery of financial targets
 Implementation of new systems
 Other key issues for resolution

Examples of key issues for resolution are provided in the table below:

Service Issues raised Solution/action

Children Speech and Remote working solution A number of lap-tops have
Language Therapy (Laptops) to be put in place been provided to enable staff
District Nursing to work remotely.
Review establishment to
Hollybank factor in Nursing Associate 2 Nursing Associates have
posts commenced in this role with 2
further undergoing their
Introduction of a forum for training programme.
Healthcare Assistants
Monthly meetings have been
scheduled and a survey
issued to staff to inform the
subjects for the meetings.

Through the attention given to services in these meetings, we have been able to focus
on ensuring they deliver high quality services and continue to improve. Detailed
examples of two of these services: Talk together Bromley and Bexley 0 to 19 Public
Health Service are detailed overleaf.

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Quality Account 2018 - 19

Talk together Bromley

Talk together Bromley: Improving Access to Psychological Therapies (IAPT) provides a
free, NHS evidence-based, talking therapy service for people aged 18 years and over,
who are anxious, stressed, have low mood or suffer from depression.

The service provides a range of treatment programmes including one-to-one therapy,
counselling and group work. The team is made up of psychological therapists,
counsellors and psychological wellbeing practitioners and deliver a stepped care
approach.

This service is commissioned by NHS England. Nationally the Five Year Forward View
for Mental Health commits to expanding services further, alongside improving quality.
This expansion means that services nationally are moving from seeing 15% of those
recorded with anxiety and depression at the end of March 2017, to 25% at the end of
March 2021. This increase in access is a real challenge for services across the country.

However, in Bromley in 2018/19, the service not only hit but exceeded all its targets
which was a huge achievement and our staff should be applauded for it. Between
January and March 2019 (Quarter 4) the service has delivered the following results

Waiting Times
National standards require 75% of people referred to IAPT services should start
treatment within 8 weeks of referral and 95% should start treatment within 18 weeks of
referral. The table below illustrates how the service routinely sees over 90% of patients
within 8 weeks of referral.

Access
The service achieved 270 over the target for new assessments at the end of Quarter 4
which was a significant achievement. This was achieved by increasing the capacity of
the team, reducing cancellations and DNAs by text reminders, delivering building
resilience workshops and delivering workshops to patients attending Walking Away
From Diabetes workshops.

The excellent performance of the service has been recognised and South East London
STP Task and Finish Group would also like to learn from the Bromley Healthcare service
on how to reduce DNAs and cancellations.

Recovery Rates
The national standard for recovery rates is that at least 50% who complete treatment
should recover. The rolling recovery rate at the end of Quarter 4, 2018/19 was 56%. This
was achieved by a focussed approach including reminding staff how to record recovery
rates properly, scrutiny of individual therapist outcomes and reviewing at supervision
patients who did not recover.

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Quality Account 2018 - 19

Long term conditions

Bromley has been recognised for its achievement for increasing accessing to patient
with long terms conditions at the SEL STP Task and Finish Group and members of this
group have asked to visit Bromley to learn from our success. In addition, NHS England
have fed back from the peer review visits they did in 18/19 that the services delivered by
community providers such as Bromley Healthcare have had the most success in
increasing access to psychological therapies to patients with Long term conditions.

Bexley 0 to 19 Children’s Public Health Service

Bromley Healthcare commenced delivering the Bexley 0 to 19 Children’s Public Health
Service in June 2017 and feedback on the service is very positive. At handover the
service had been performing sub optimally and many of the KPIs in place were not being
delivered. Since taking over the service the majority of KPIs are either being delivered
above the target of 90% or close to it.

No additional resource was added to the service at inception, but delivery of the service
was reviewed with a focus on ensuring that all families were offered a face to face
universal contact to deliver the mandated checks, commencing within the antenatal
period. These contacts ensure that a ‘Family Health Needs Assessment’ is done on all
families seen either in the ‘Antenatal’ period or at the ‘New Birth’ visit at 10-14 days,
which helps identify those families who require additional support from the service.

Where indicated targeted support is offered using evidence based interventions through
a whole family approach ensuring appropriate support such as Portage or the Wellbeing
service. Where there is a concern that there is a risk of significant harm, families are
referred to Children’s Social Care through the Multi-Agency Safeguarding Hub.
Whenever possible, this referral is always discussed with the family first.

100.00% Mandated Checks 0-4 years
90.00% Target 90%
80.00%
70.00% Quarter 1 18/19
60.00% Quarter 2 18/19
50.00% Quarter 3 18/19
40.00% Quarter 4 18/19
30.00%
20.00%
10.00%
0.00%

Figure 3.6 Mandated Checks 0-4
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Quality Account 2018 - 19

In addition to the universal offer where mandated checks are routinely delivered at
90% or above (see figure 3.6), staff work hard to support mothers with breast feeding
and there has been a significant increase in the breast feeding rates at 6-8 weeks (see
figure 3.7).

Increase Breast-feeding rates at 6-8 weeks
(Target 43%)

56.0% 53.90% 54.60% Increase Breast-feeding rates at
54.0% 52.80% 6-8 weeks
52.0% 47.4%
50.0%
48.0%
46.0%
44.0%
42.0%

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Figure 3.7 Increase in breast feeding rates at 6-8 weeks

In order to achieve this increased uptake of the mandated checks, the service reviewed
the number of child health clinics being delivered and freed up health visitor capacity by
closing the clinics with poor attendance. In order to ensure families were happy with the
new clinic provision, an audit was done in all clinics in February 2018 and the results
from this were available in April 2018. 586 parents completed the audit form. This
highlighted that 96% of respondents were very satisfied or satisfied with the changes.

Are you happy with the Clinic?

Very Satisfied Satisfied
Neither satisfied or dissatisfied Dissatisfied
Very dissatified Not answered

0% 0% 3%
1%

18%

78%

Figure 3.8 Satisfaction with clinic setting

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Quality Account 2018 - 19

There were 230 comments written on the feedback forms. 87% of these comments
were only positive, 5.65% gave positive and negative feedback and 7.4% gave
constructive feedback where changes could be made for the better. Comments
included the following:

“I have never had to wait longer than 10 minutes. Staff always happy and very
helpful.”

“Very nice Health Visitor, helpful and kind. Nice staff, clean place, warm and
lovely.”

“No wait at all. Very happy.”

“Lovely clinic.”

“My baby clinic closed in November so I have been coming here since. I like
coming here. It is clean, very friendly staff, the professionals are very useful.”

“Very through discussion with the Health Visitor. She listened and gave good
advice. I did not feel rushed.”

“Service is excellent.”

“Amazing service, very friendly and helpful”

More challenging was the mobilisation of the School Nurse element of the service.
When Bromley Healthcare took over the service, there was only one School Nurse
employed by the previous provider in Bexley and it has taken time to recruit to these
vacancies due to a national shortage of School Nurses.

The School Nurse team deliver the National Child Measurement Programme (NCMP)
measurements and vision and hearing checks in primary schools and at the end of the
academic year in July 2018 the service had exceeded the target in all areas.

The School Nurses engage with schools in terms of the Year 7 and Year 11 contact
and work in close partnership with schools and Social Care to help ensure that children
and young people are safeguarded from harm. This includes completing an “It’s All
About Me questionnaire” with all children and young people referred to Social Care
thus ensuring the voice of the child is heard.

The service has a well-developed website at bexley0to19.co.uk with resources for
parents, children and young people, as well as offering a virtual service through the
Live Chat function between 9am to 5pm, Monday to Friday. See screenshots from the
website in figure 3.9 overleaf.

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Quality Account 2018 - 19

Figure 3.9 Website screen shots
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Quality Account 2018 - 19
784 Friends and Family Tests were completed by Bexley 0 to 19 service users in 18/19
with a response rate of 3.98%. From these responses 97.1% are extremely likely or
likely to recommend the service.

Figure 3.10 Bexley 0 to 19 service Friends and Family Test results 2018/19
Health Visiting comments received from parents include:
 “Really caring and helpful advice, extremely happy”
 “Kind supportive and gentle and loads of information”
 “Provided with good hints and tips regarding toilet training, speech and encouraging

self spoon feeding”
 “Friendly and warm”
 “No waiting, a prompt service”
School Nursing comments received from young people include:
 “Sue was so kind, really helpful and informative. I really appreciate it thank you”
 “It was good because now I know what to do”
 “Learning that there are people to help me while I am at school”
The Bexley 0 to 19 Children’s Public Health Service has really flourished under Bromley
Healthcare and all credit goes to the committed, hardworking staff.

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Quality Account 2018 - 19

Our Aim Achievement

Development and delivery of outcome measures Complete

Clinical outcomes are measurable changes in health, function or quality of life that result
from our care. Constant review of our clinical outcomes establishes standards against
which to continuously improve all aspects of our practice BHC has a clinical outcome
measured contract with Bromley CCG and both adult and children’s clinical services
have developed and agreed clinical outcomes over the past year to measure and
evidence that they are providing the best clinical care. This is a new way of monitoring
the services that we provide consistently.

21 of our services now have these clinical outcomes measure in place which are
routinely reported as part of contract and performance monitoring process. These are
also monitored externally through our CCG contract monitoring meetings.

Therapy Outcome Measures (TOMs) is a standardised tool that measures the impact of
a person’s condition across four areas

Impairment (problems in body structure or function)
Activity (performance of activities)
Participation (impact on daily life roles/interpersonal interaction)
Wellbeing (emotional level of upset or distress)

The TOMs tool allows the healthcare provider to measure not only the changes in the
person’s condition, but how this impacts their daily life, their psycho-social gain and their
wellbeing. The tool can also measure the impact the care has on the carer’s wellbeing.
Bromley Healthcare has implemented use of TOMs across a number of its services; the
results of a sample of services are detailed below. For the purposes of this measure if
improvement was seen in two or more areas this was considered an improvement in the
clinical outcome.

Our Adult Physiotherapy, Occupational Therapy, Speech & Language Therapy, Falls,
Wheelchair, Rehabilitation Beds and Home based services are all using TOMs to
measure their outcomes. Our initial success with this nationally recognised outcome
measure was reported in last year’s Quality Account.

Two examples of our service outcomes are detailed below for our Tissue Viability and
Children's Physiotherapy service.

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Quality Account 2018 - 19

Tissue Viability (Leg Ulcer) service

The Tissue Viability service works to improve the quality and standards of care for all
patients in the community who have recognised tissue viability needs. The service
provides assessment, diagnosis and treatment of patients. The team act as experts
educating practitioners involved in the care of patients to deliver best practice according
to national and local guidelines and expert opinion, making referrals to secondary and
tertiary care as appropriate.

Tissue Viability is a specialist service outside of hospital for patients with complex
wounds and highly complex needs, the service incorporates telephone advice, home
visits, and visits to GP surgeries, residential homes, nursing homes, intermediate care,
special needs schools and clinics for people of all ages that are registered with a
Bromley GP.

The Leg Ulcer service sits within the Tissue Viability service. This service is clinic based
and provides assessment, diagnosis and treatment for mobile Bromley patients that
present with a lower leg wound. The service has implemented two outcome measures:

 Simple leg ulcers aim to be healed within 12 weeks
 Complex leg ulcers aim to be healed within 18 weeks

The service began measurement of these outcomes in October 2018. Between October
2018 and March 2019 the service was able to demonstrate that 88% of simple venous
leg ulcers were healed within 12 weeks and 100% of complex venous leg ulcers were
healed within 18 weeks.

Children’s Physiotherapy

The service provides assessment, support, instruction and therapy to children and
young people with physical difficulties or disabilities. Therapy may involve activity and
exercise programmes, individual or group sessions or aquatic therapy.

The Physiotherapy team work collaboratively towards enabling children and young
people and their families to manage their own physical health needs and maximise
physical potential. Examples of when physiotherapy may be needed include delay in
development, mobility problems, neuromuscular disorders, neurological conditions,
balance and co-ordination difficulties, joint and muscle pain problems

At the beginning of a programme of treatment a series of goals are set and agreed with
the child and family. On completion of treatment these are reviewed. The service began
measurement of these outcomes in October 2018. Between October 2018 and March
2019 the service was able to demonstrate 93.5% of goals set and agreed have been
achieved for children and families.

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Quality Account 2018 - 19

Safe and Caring – Patient at the centre of care

Our Aim Achievement

Utilise patients feedback to drive service improvements Complete

Patient Reference Group

In 2018/19 the Patient Reference Group was expanded and a focussed approach taken
to use the forum to feedback on our services and recommend improvements.

The Bromley Healthcare Patient Reference Group meets quarterly, the group is led in
partnership and supported by Bromley Healthwatch and chaired by our Chief Executive.
The group enables local residents and service users to share their experiences and offer
positive support in ensuring public and patient involvement is at the heart of our services
and business functions.

The members provide feedback and engagement on our services, activities,
communication tools and plans that Bromley Healthcare presents. These include
suggestions on changes that we should make and on areas for further development.

The group this year supported a review of our service leaflets and standard letters to
patients such as did not attend letters. The group has additionally carried out a review of
our website. All these activities have led to recommendations on improvements to our
communication channels to ensure they are patient public friendly and easy to
understand.

The group has received range of presentations on our services allowing the group to ask
question and provide input to how services could improve for patients and their families.
The services who have presented include Diabetes, Talk Together Bromley, Community
Paediatrics, Rehabilitation services, Tissue Viability and Lymphoedema services.

Our Care Co-ordination Centre (CCC) has been the subject of a mystery shopping
exercise by members of the patient reference group. The group has provided feedback
on their experience and advice on how the CCC can improve the experience of the
service user.

Other topics reviewed this year at the group include our nursing associate programme,
recruitment initiatives and our apprenticeship programme.

The group receives a regular update in the form of a “You Said, We Did” document
which ensure the PRG members are kept fully up to date on the impact of their
suggestions.

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Quality Account 2018 - 19

Direct service surveys

Our services regularly complete their own direct surveys with their patients in order to
gather specific feedback to help us shape the service moving forward.

An example of this is our Children’s Occupational Therapy service which collected
feedback from parents and achieved an 80% response rate. Parents attending an
appointment in the main occupational therapy treatment room were asked to complete
the (Extended) Friends and Family Feedback questionnaire at the end of the
sessions. In order to support honest feedback from parents, parents were asked to place
the questionnaire in the survey box in the room, and not to hand it personally to the
therapists.

 99.5% of parents said they were extremely likely or likely to recommend the
service.

A large proportion of feedback commented on friendly, welcoming and professional
staff. A number of comments were made about parents feeling understood and that
staff treated their concerns with empathy and kindness. Parents valued staff’s
patience and the time the OTs took to explain their recommendations.

A large proportion of parents reported feeling that their concerns were listened to.

A large proportion of feedback shows that parents valued having clear advice and practical
tips and strategies that they could implement immediately. A number of comments
refer to valuing the advice given around making tasks that their child was struggling
with easier and appreciated it when information was explained simply to them.

A number of comments stated that parents felt the service was child-centred and the
OTs had a good way of interacting with their child. The staff’s good communication
skills were noted by a number of parents.

A number of comments show parents felt that they had received a thorough and detailed
assessment and that the assessment was tailored to their child’s particular needs.

At the end of each month, action plans were put in place in response to the feedback
obtained. Examples of service improvements following service user feedback include:

 Following comments around wanting advice sheets to take away immediately from
the assessment, advice sheet holders were placed in clinic room for parents to
take away.

 The writing resources were updated in the OT treatment rooms have been expanded
to include a wider range of assessment stock for therapists to use with children.

 Due to comments around requesting advice clinics, advice sheets and therapy
homework. It is made clear to parents that they can bring their children to the
advice clinic within two years of being seen for assessment. The OT section on
the Bromley Healthcare website has recently been updated to improve
communication.

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Quality Account 2018 - 19

Monitoring patient experience

Bromley Healthcare monitors and measures patient experience through the Friends and
Family Test, Care Opinion feedback, and the 4Cs) compliments, comments, concerns
and complaints). Information is used to drive improvements in our services. The
following provides a summary of these elements for the year.

The Family and Friends Test (FFT)

The Friends and Family test asks the users of our services how likely they would be to
recommend the service to a family member or friend should they need it. Bromley
Healthcare continue to perform well as an organisation repeatedly coming top in London
and usually in the top 5 nationally. For 2018/19 98% responded as either likely or
extremely likely to recommend our services as illustrated in Figure 3.11.

Friends & Family Responses
April 18 - March 19

1% 1%

98%

Extremely Likely / Likely Neither Likely/Unlikely/Don't know Extremely Unlikely / Unlikely

Figure 3.11: FFT results Bromley Healthcare

Care Opinion

Bromley Healthcare continues to use the web based Care Opinion. Patients, carers
and the public have the opportunity to tell their story and experiences of care provided.
An option of using pictures as feedback is available to those clients who have
communication difficulties including clients with Dementia. Bromley Healthcare responds
to all feedback on Care opinion and is currently the only organisation with a 100%
response rate. A sample of feedback taken from Care Opinion is provided overleaf.

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Quality Account 2018 - 19

“I went with my 86 year old husband to Biggin Hill Bladder and Bowel
clinic this morning at 9.30. We saw a very nice young person who gave us
lots of advice on how to manage the bladder problems my husband was
experiencing. We were also told that my husband has a water infection;
this may have been contributing to the problems and to his confusion,
although he also has Alzheimer’s. He’s been given antibiotics and will
have a follow up in 8 weeks time. This is very reassuring as I know that
someone is monitoring what is happening and will be able to offer more
help and advice.
My husband was treated with great care and dignity; I cannot be more
appreciative of the way we were treated.”

“I developed PTSD after a serious car accident. 8 months after the
accident my GP suggested I contact Talk Together Bromley and I was
offered space in a small group. I had 4 sessions in the group.
The group surpassed all my expectations, the therapists were so down to
earth and made me feel comfortable. The group sessions taught me why
we develop PTSD which really helped me understand my trauma. I then
received about 13 one to one sessions with one of the CBT Therapists
who had run the group. I had no idea how life changing these sessions
would be. I felt like no stone was left unturned. It was a challenging
course but Claire was there every step pf the way supporting me through
reliving the trauma until it was properly processed. By the end of the
therapy I felt entirely different to how I was at the start. I can talk about
the accident now and things that remind me of it. I feel like it’s not waiting
to come back and bite me anymore because it’s all worked through. I will
keep referring to all I learned and worked through in years to come and I
am so grateful for this therapy.”

Today I visited the Phoenix Centre Contraceptive Clinic and had the most
amazing experience. I was greeted by the Health Care Assistant who was
very friendly and very efficiently checked me in. Then had the most
wonderful appointment to get an implant fitted with the nurse. She was
incredibly diligent, friendly and caring. It felt like meeting a friend. They
made me feel very comfortable.

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Quality Account 2018 - 19

Compliments, complaints, comments and concerns (4Cs)

The following table provides a summary of the 4Cs received by services this year in
Figure 3.12

Q1 Q2 Q3 Q4

14/15 complaint 30 26 32 28
15/16 concern
16/17 compliment 19 29 17 22
17/18 complaint
18/19 concern 138 194 257 120
compliment
complaint 25 14 24 20
concern
compliment 23 30 33 38
complaint
concern 147 143 193 139
compliment
complaint 12 10 11 16
concern
compliment 29 19 26 26

123 118 126 80

10 17 24 35

18 45 40 29

79 97 115 88

36 22 33 8

64 61 55 42

184 580 164 106

Figure 3.12 4 C’s summary

Complaints

Whilst we strive to ensure our patients don’t have reason to complain, complaints do
provide an invaluable opportunity to review patient care, our services and the way in
which we interact and provide information to patients and their carers. Lessons learnt
from complaints help to drive service improvement.

Once the complaint has been investigated we write to the complainant and inform them
of the results of the investigation. We provide details of the learning and actions that
have been taken. This year our service user involvement group helped to develop a
dedicated leaflet to enable people who use our services to know how to make a
complaint if required.

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Quality Account 2018 - 19

The number of complaints that have been dealt with in the period 2018/19 remains
steady. However there has been a significant increase in the number of concerns. This
is due to the fact that staff have been better at contacting clients directly and dealing
with issues at an early stage thus preventing escalation to a formal complaint.

Even though the number of compliments received has more than doubled in the last
year it does not reflect the true figure as many staff find it hard to accept that they should
document personal positive feedback. We continue to actively encourage our staff to
record all compliments.

This year has seen the establishment and implementation of a weekly Incidents and
Complaints meeting. This meeting is chaired by the Chief Executive and attendees
include the Medical Director, the deputy Director of Nursing and Safer Care and Head of
Safer Care. All new incidents and complaints are discussed and actions put in place for
improvement where possible.

Examples where services have shown learning from complaints

Misleading or lack of As a result of a number of complaints the Patient Reference
information on the Group have played an integral role in reviewing and commenting
service website upon service websites and service leaflets. Changes have been
made to the website accordingly.

Domiciliary Visit: The protocol for staff in the event that they are unable to access
a client’s home was updated , discussed at our clinical
Inability to access a
client’s home Leadership meeting and circulated to all patient facing staff

across the organisation

Complaints regarding The Manager audited the response times to telephone calls, and
delays in voice mails, as well as feedback. As a result the options for
communication early patients to choose when they dial in were reviewed and
on in the simplified all as a result of feedback from patients and clinical
establishment of a staff. A ‘ mystery shopping exercise undertaken by members of
centralised Care the Patient Reference Group also provided feedback enabling
Coordination Centre improvement in the system. As a result the number of concerns
relating to this service has reduced dramatically.

Complaints regarding All staff involved in these concerns are interviewed by senior
the quality of clinical clinicians and their competency to deliver that particular element
care of care re assessed. If necessary training is put in place.

Talk Together Bromley: A process change was implemented, whereby, in future the
Complaint from client service will routinely invite patients into the service for a further
experiencing detailed face to face assessment where there has been a
deterioration in change or deterioration in functioning/circumstances for patients
symptoms while on on a waiting list for therapy. Previously this has been done by
waiting list telephone.

Figure 3.13 Examples of learning from complaints 2018/19
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Quality Account 2018 - 19

Our Aim Achievement

Introduction of a preventative (near live) patient safety Complete
dashboard

Bromley Healthcare has been developing a range of near live service and organisation
performance dashboards during 2018/19. As our commissioners Bromley CCG benefit
from the improved level of data collection through routine contract reporting and the
ability to support deep dives. This work has expanded its remit to place a specific focus
on the development of safety dashboards. In the first instance this has focussed on the
completion of insulin injections by the District Nursing (DN) service.

This initiative as well as being a Bromley Healthcare Quality objective for 2018/19 was
adopted by Bromley CCG as one of our CQUIN schemes.

We have invested significant time, expertise and resource to develop its existing near
live dashboards. Our first step towards a live safety dashboard was in the form of a pilot
with one of the DN teams to establish one aspect of a safety dashboard focusing on the
provision of housebound insulin injections. This pilot allowed us to identify in near real
time the completion of the insulin injections and ensure any potentially missed injections
were picked up and completed on the same day through a clear escalation process. The
dashboard is now being used on a daily basis. The insulin audit is run daily at 2.15pm. If
the report highlights any injections which have not been given these are followed up
through the Care Co-ordination Centre. If necessary the twilight nursing team will pick up
any outstanding injections ensuring on a daily basis that all patients receive their
required insulin injection

This forms the basis of a wider reaching dashboard as part of future work.

Caring and Well Led – Culture for Growth

Our Aim Achievement

Grow our own team strategy Complete

Appraisal

The NHS Constitution requires organisations to provide staff with clear roles and
responsibilities, personal development and line management, to support them to succeed.
An organisation-wide appraisal process, that focuses on performance and personal
development, helps deliver this. As such Bromley Healthcare ensures all managers and
staff have allotted time to complete their appraisals and to support regular ‘one to ones’.

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Quality Account 2018 - 19

Appraisals are a fundamental tool which supports individual development within their role
and through promotion within the organisation. Our organisational aim is that a minimum
of 85% of staff achieve a regular annual appraisal. For all months in 2018 /19 we were
above our target of 85% for all staff having an appraisal.

Reducing time to recruit
To support our active recruitment campaigns to reduce our vacancies for clinical and
non clinical posts we have reduced our time to recruit to posts from 50 to 34 days.

Reducing vacancies
Our overall vacancy rate has reduced from 12.8% to 7.07%. Our focus on our District
Nursing workforce has seen vacancies reduce from 20% to 11.9% and as we have
optimised the Care Coordination Centre vacancies have reduced from 30% to 11.5 %,
see figure 3.14 below.

Figure 3.14 Care Co-ordination Centre vacancies

Internal Promotion
We encourage the development of our staff. During 2018-19 we supported 46 people to
achieve internal promotions

Our Aim Achievement

New Programme in Place for District Nursing Complete

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Quality Account 2018 - 19

Introduced a Band 5 Development Programme

District Nursing is the largest workforce group employed by Bromley Healthcare. The
nature of nursing in community healthcare requires staff to work remotely with limited
supervision compared to other healthcare environments. This can be particularly
challenging for less experienced nurses and can have a negative impact on both
recruitment and staff retention.

Our organisation is also challenged with ensuring a District Nursing workforce, providing
the wide range of skills and competencies required with staff able to operate
independently, where possible.

To address these issues Marie-Louise Muir, Community Clinical Educator (Nursing) with
her team, proposed and developed an intensive course that would revolutionise the way
Bromley Healthcare train nursing staff. The Band 5 Development Programme (10 weeks
duration) was designed for newly registered nurses and provided focussed targeting of
clinical skills, immediately followed by clinical practice with tailored lists of patients e.g.
practical application of catheterisation within 3 days of training in the competency. The
course ensured that by the end of the 10 week period community nursing staff were fully
competent in the essential skills for their roles. Great care was then taken to seamlessly
transition the nurses into the preceptorship programme.

Marie-Louise sourced experienced supernumerary clinical supervisors/trainers,
employed on Bank, to provide intensive support, without affecting service delivery for
patients. This required meticulous planning and organisation across multiple teams and
an investment in time which was intensive for the Learning and Development Team and
Marie-Louise in particular. Financial impact and benefit papers were presented to our
Executive Team for approval and to gain confidence to take the project forward.

No projects locally offered a similar level of intensive training to new community nurses
at the scale that we required. The whole programme had to be devised by adapting
existing courses underpinned by our detailed knowledge of nursing development.
Project management and engagement with other teams was critical to the success of
the project, as well as in depth knowledge of what was required for these staff and could
only truly be achieved by someone with skill in both areas, which Marie-Louise provided.

By working in partnership with Universities, local organisations i.e. St Christopher’s
Hospice and Bromley Healthcare teams, Marie-Louise ensured that these new Band 5
nurses had a seamless initiation into the organisation and aligned services from all
aspects. This included basics from uniform and equipment right the way through to
individual clinical supervision and activity allocation.

The inaugural programme was delivered from 3rd September 2018 to 9th November
2018. We intend to complete further evaluation in terms of the effects on staff retention
and patient experience and health outcomes over the coming year. We do know on
evaluation that the staff that were part of the programme were very satisfied with the
course delivery and the benefits they gained from the programme with increased
confidence in their role.

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Quality Account 2018 - 19

Lessons learned have been shared throughout Bromley Healthcare and will inform
future programmes for learning and development. Our next Band 5 Development
programme is scheduled for September 2019

Introduced Nursing Associate roles to our workforce

2018/19 saw the establishment or our Nursing associates programme. The programme
will start to deliver results over the coming year

Nursing associates are new members of the nursing team providing care and support for
patients and carers; they bridge the gap in skills and knowledge between healthcare
assistants and registered nurses. Across the country, Nursing Associates have started
to work in general medical and surgical wards, care of the elderly and community
services like ours.

Nursing associates undertake a two year training course, leading to a foundation
degree. The training enables them to work with people of all ages and in a variety of
settings in health and social care. They have attended a number of practical
placements in different settings; in hospital, close to home and at home. We have a
cohort of Apprentice Nursing Associates starting their training in 2019 and two Nursing
Associates graduated in April and began working in the Rehabilitation Service in
Foxbury and in the Beckenham Community team.

Nursing Associates training covers the following areas of proficiency:

1. Be an accountable professional

2. Promoting health and preventing ill health

3. Provide and monitor care

4. Working in teams

5. Improving safety and quality of care

6. Contributing to integrated care

Nursing Associates are regulated by the Nursing and Midwifery Council and so their
registration will have to be revalidated every three years, providing additional quality
assurance and protection for patients and carers.

Employers like Bromley Healthcare are responsible for assuring that practicing Nursing
Associates have the qualifications, competence, skills and experience to undertake the
activities required of them, including medicines management.

Nursing Associates are educated to understand medicine management, but have to be
signed off as competent and work within our local policies and guidelines to administer
prescribed medicines safely and appropriately.

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Quality Account 2018 - 19

Although they work autonomously, Nursing Associates work under the supervision of a
registered nurse on a delegated caseload, providing a wide range of hands on care and
interventions. This lets our registered nurses focus on more complex cases.
As with all of our nurses, they follow our code of conduct and adhere to the 6Cs; care,
compassion, competence, communication, courage and commitment.
There are 6 new nursing associates scheduled to take up roles in the organisation in the
coming year.

Production of recruitment films
During 2018 to support our priority to recruit to nursing vacancies a number of our
nurses contributed to the production of a District Nursing recruitment film and also a Day
in the life of a District nurse film.
These films are hosted on the Bromley Healthcare You Tube channel and are available
to prospective employees via our website, social media accounts and NHS jobs.
The recruitment films can be viewed at:
youtube.com/channel/UCXqdJm17dcbXnfvh98qlJ0g

A dedicated focus on nursing recruitment
Bromley Healthcare has undertaken a number of recruitment programmes that have had
a focus on our district nursing workforce. Some of the methods used include:
 Diversified where adverts are placed using additional media such as Jobsite, various

publications and specialist websites
 Advertising on Buses
 Advertising on Radio
 Using social media (twitter & linked IN)
 Holding several specific recruitment events such as open days and assessment

days targeting district nurses and newly qualified nurses

Reduction in nursing vacancies
The collective impact of the initiatives above has seen a reduction in our vacancies
within the District Nursing service and is illustrated overleaf in Figure 3.15

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Quality Account 2018 - 19

Figure 3.15 District Nursing Vacancies 2018

Our Aim Achievement

Apprenticeship programme in place within the Care Complete
Coordination Centre

In last year’s Quality Account we detailed the start of our journey to embrace the
benefits of supporting apprenticeship programmes. Apprenticeships can help
businesses across all sectors by offering a route to harness new talent.
Apprenticeships in health services provide routes into a variety of careers and are an
excellent opportunity to earn, gain work experience and achieve nationally recognised
qualifications at the same time.

From April 2017, the government made significant changes to the way it funds and
delivers apprenticeship training. Bromley Healthcare pays an apprenticeship levy to
the HMRC each month, which is used to fund apprenticeship training within the
organisation. Apprenticeships today can be at different academic levels, from entry
level, all the way up to Degree apprenticeships and are available to anyone over 16,
not just school leavers, so they can also help people retrain and change careers.

In Bromley Healthcare, the apprenticeship scheme encourages engagement with the
local community, providing employment opportunities for people aged 16 years and
over.

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Quality Account 2018 - 19

For example, we have actively engaged with schools to raise the profile of
apprenticeship opportunities for those school leavers who have yet to find employment
after leaving education. Apprenticeships have also been showcased at careers
discovery days. Apprenticeship opportunities have been offered to existing staff and as
new roles open to external recruitment.

Apprenticeship providers deliver the theoretical requirements of the apprenticeship,
working with the apprentice and their manager to ensure the skills, knowledge and
behaviour requirements of the apprenticeship standard are accomplished. Quality
Assurance is provided through the following processes:

 Institute for Apprenticeships standards: All apprentices have a development
programme for 12 months based on Institute for Apprenticeships standards. For
example apprenticeships in the Care Coordination Centre are matched to the
Customer Service Apprenticeship Standard: Customer Service Practitioner level 2.
This includes an assessment plan which sets out the requirements and process for
the end point assessment.

Internal quality assurance is provided through:

 Robust contract management of apprenticeship providers

 An apprentice forum, meeting 4 times per year to discuss concerns and issues and
share learning

External quality assurance: all providers are required to be registered and be accredited
as a provider with the Institute for Apprenticeships. Bromley Healthcare has appointed 7
apprentice roles into our Care Coordination Centre:

Apprenticeship Service Number of
Customer Service Practitioner Care Coordination Centre Apprenticeships
Business Administration Care Coordination Centre
6

1

In March 2019 Runway, the apprentice provider for these apprenticeships, had its
annual awards.

Bromley Healthcare was nominated and some of our apprentices received individual
nominations. Two of these apprentices deservedly won awards.

Paige Ansary was the winner of the Level 2 Apprentice of the Year Award and James
Tucker also received an award as a finalist in the Level 2 Apprentice of the Year
Awards. Bromley Healthcare was also a finalist in the Apprenticeship Employer of the
Year Award category.

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Quality Account 2018 - 19

Feedback from our CCC apprentices and their manager:

"Doing the apprenticeship, everything we learn is relevant and useful to the
work we do in the CCC and it was great all the apprentices starting together"
"I really appreciate the on the job training. I'm always learning something new
and the apprenticeship has really taught me how to multi-task!"
"The Customer Care apprenticeship has been amazing, a great opportunity and
working with patients and colleagues has really improved my confidence and
ability to talk to people".
" The apprentices are keen and eager to learn and develop in their roles and
have risen to the challenge of working in a busy environment like the CCC

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Quality Account 2018 - 19

Success Stories

This section highlights any particular successes delivered in 2018-19 which are not
picked up in the prior section.

Relocation of our Rehabilitation Beds

The Bromley Healthcare bedded rehabilitation unit relocated to a newly renovated and
bespoke setting at Queen Marys, Sidcup on 20 December 2018. This involved the safe
transfer our 28 patients between sites.

Patient safety was at the centre of our move planning. The unit had been fully pre-
equipped in advance of the move to ensure a smooth transfer and continuity of service.
On the move day, a Command Centre, staffed by a senior operational staff, directed the
physical transfer process of patients and staff and ensured continuity of service
provision during the transfer period. The physical transfer of the patients did not
commence until the Command Centre were satisfied that all necessary arrangements
were in place. Assurance was provided by completion of move checklists which
including confirmation that the patients were fit to travel. On arrival at the unit all patients
were provided with a meal and settled into their new accommodation
Patients and their families had been involved in detailed discussions preparing them for
the move and answering any questions. All our partner providers were fully briefed on
the service change including hospital team which ensured we were able to admit
patients to the unit on the day of transfer. Patient feedback about the move itself and the
new location were uniformly positive:
“The transiting from Lauriston to Foxbury was excellent”
“The environment is clean and bright”
“The Food is very good and hot”
“Very happy with his care at Foxbury”

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